Gynecology Oncology

·         Fibroadenomas are the second most common benign breast disorder, after fibrocystic changes. They are characterized by being firm, solid, nontender, and freely mobile. Fibroadenomas have an average size diameter of 2.5 cm and are well circumscribed. These lesions most commonly occur in adolescents and women in their twenties. Fibrocystic changes occur in about one-third to one-half of reproductive-age women and represent an exaggerated response of the breast tissue to hormones. Patients with fibrocystic changes complain of bilateral mastalgia and breast engorgement preceding menses. On physical exam, diffuse bilateral nodularity is typically encountered. Cystosarcoma phyllodes are rare fibroepithelial tumors that constitute 1% of breast malignancies. These rapidly growing tumors are the most frequent breast sarcoma and occur most frequently in women in the fifth decade of life. Trauma to the breast can result in fat necrosis. Women with fat necrosis commonly present to the physician with a firm, tender mass that is surrounded by ecchymosis. Occasional skin retraction can occur, making this lesion difficult to differentiate from cancer. It is unlikely that this patient who presents in her twenties has breast cancer.

·         The Gail model is a computer model that analyzes a woman's various risk factors to give her an "accurate," individualized risk assessment. This model includes some of the above identified risk factors. It does not include whether or not a woman has been tested for the BRCA gene. It also does not consider the use of HRT.

·         The vagina as a secondary site of another cancer is more common than primary vaginal cancer.

·         Extensive evidence indicates that infection with certain high-risk subtypes of human papilloma virus (HPV) (types 16, 18, 31, 45, 51-53, 58, or 58) is an important etiologic event. Though the exact mechanism of malignant transformation has not been entirely elucidated, it is clear that HPV oncoproteins E6 and E7 impair proliferation inhibition by blocking the function of the p53 and retinoblastoma tumor suppressor pathways.

·         There is no screening method for ovarian cancer since CA-125 is nonspecific and transvaginal ultrasound is not cost-effective.

·         The term Krukenberg tumor describes metastatic adenocarcinoma of the ovary that contains significant numbers of signet ring cells in a cellular ovarian stroma.

·         When you teach a patient to perform a breast self-exam, you should recommend that it be performed monthly, a few days after the menses. It is best to perform the breast exam in both the erect and supine positions. Asymmetry of the breasts is common in most women, but any recent changes need to be reported. Any nipple discharge should be reported immediately to a physician, because it can be associated with an underlying tumor.

·         The main routes of spread of cervical cancer include vaginal mucosa, myometrium, paracervical lymphatics, and direct extension into the parametrium. The prevalence of lymph node disease correlates with the stage of malignancy. Primary node groups involved in the spread of cervical cancer include the paracervical, parametrial, obturator, hypogastric, external iliac, and sacral nodes, essentially in that order. Less commonly, there is involvement in the common iliac, inguinal, and paraaortic nodes. In stage I, the pelvic nodes are positive in approximately 15% of cases and the paraaortic nodes in 6%. In stage II, pelvic nodes are positive in 28% of cases and paraaortic nodes in 16%. In stage III, pelvic nodes are positive in 47% of cases and paraaortic nodes in 28%.

Cervical cancer is still staged clinically. Physical examination, routine x-rays, barium enema, colposcopy, cystoscopy, proctosigmoidoscopy, and IVP are used to stage the disease. CT scan results, while clinically useful, are not used to stage the disease. Stage I disease is limited to the cervix. Stage Ia disease is preclinical (i.e., microscopic), while stage Ib denotes macroscopic disease. Stage II involves the vagina, but not the lower one-third, or infiltrates the parametrium but not out to the pelvic side wall. IIa denotes vaginal but not parametrial extension, while IIb denotes parametrial extension. Stage III involves the lower one-third of the vagina or extends to the pelvic side wall; there is no cancer-free area between the tumor and the pelvic wall. Stage IIIa lesions have not extended to the pelvic wall, but involve the lower one-third of the vagina. Stage IIIb tumors have extension to the pelvic wall, and/or are associated with hydronephrosis or a nonfunctioning kidney caused by tumor. Stage IV is outside the reproductive tract.

a positive IVP would mean extension to the pelvic side wall and thus a stage III carcinoma, specifically stage IIIb. Such staging applies even if there is no palpable tumor beyond the cervix.

Radical Hystrectomy involves excision of the uterus, the upper third of the vagina, the uterosacral and uterovesical ligaments, and all of the parametrium, and pelvic node dissection including the ureteral, obturator, hypogastric, and iliac nodes. Radical hysterectomy thus attempts to preserve the bladder, rectum, and ureters while excising as much as possible of the remaining tissue around the cervix that might be involved in microscopic spread of the disease. Ovarian metastases from cervical cancer are extremely rare.

·         Different tissues tolerate different doses of radiation, but the ovaries are by far the most radiosensitive. They tolerate up to 2,500 rads.

·         An important feature of the lymphatic drainage of the vulva is the existence of drainage across the midline. The vulva drains first into the superficial inguinal lymph nodes, then into the deep femoral nodes, and finally into the external iliac lymph nodes. The clinical significance of this sequence for patients with carcinoma of the vulva is that the iliac nodes are probably free of the disease if the deep femoral nodes are not involved. Unlike the lymphatic drainage from the rest of the vulva, the drainage from the clitoral region bypasses the superficial inguinal nodes and passes directly to the deep femoral nodes. Thus, while the superficial nodes usually also have metastases when the deep femoral nodes are implicated, it is possible for only the deep nodes to be involved if the carcinoma is in the midline near the clitoris.

·         Mesonephroid carcinomas tend to be associated with pelvic endometriosis.

·         Gonadoblastomas frequently contain calcifications that can be detected by plain radiography of the pelvis. Women who have gonadoblastomas often have ambiguous genitalia. The tumors are usually small, and are bilateral in one-third of affected women.

·         Mixed Müllerian tumors refer to the combination of heterologous elements—that is, tissue of different sources.

·         Uterine leiomyosarcomas are smooth muscle malignancies characterized by more than 5 mitoses per 10 hpf. These malignancies are not thought to arise from benign fibroids but occur de novo. Uterine leiomyosarcomas typically occur in postmenopausal women with a rapidly enlarging uterus.

·         Medical treatment of endometriosis currently involves a selection of four medications—oral contraceptive pills (OCPs), continuous progestins, danazol, and GnRH analogues.